What are the primary recommendations for managing uncontrolled diabetes?

Managing Uncontrolled Diabetes: Primary Recommendations

For patients with uncontrolled diabetes, the primary recommendation is to implement a comprehensive treatment approach including appropriate medication therapy (insulin for type 1 diabetes or a combination of medications for type 2 diabetes), lifestyle modifications, and regular monitoring to achieve glycemic targets and reduce complications. 1

Initial Assessment and Treatment Strategy

For Type 1 Diabetes:

• Multiple daily insulin injections or continuous subcutaneous insulin infusion is the cornerstone of treatment 2
• Use insulin analogs over human insulins to minimize hypoglycemia risk 2
• Early implementation of continuous glucose monitoring to improve outcomes 2
• Consider automated insulin delivery systems 2
• Provide education on matching mealtime insulin doses to carbohydrate, fat, and protein intake 2

For Type 2 Diabetes with Marked Hyperglycemia (HbA1c ≥10%):

• Start with long-acting insulin (0.5 units/kg/day) plus metformin for patients with HbA1c ≥8.5% without acidosis 1
• For patients with HbA1c ≥10%, consider insulin therapy essential when diet, physical activity, and other antihyperglycemic agents have been optimally used 3
• High-potency GLP-1 receptor agonists or dual GIP/GLP-1 receptor agonists can be considered as alternatives to insulin for patients with BMI ≥27 kg/m² 1

Lifestyle Modifications

• Aim for 7-10% weight loss for patients with overweight/obesity 1
• Engage in at least 150 minutes per week of moderate-intensity aerobic activity 2, 1
• Follow a heart-healthy diet limiting daily fat intake to 30% or less of calories, with less than 7% from saturated fat 2
• Limit sodium intake to <2,300 mg/day 2
• Reduce sedentary behavior 1
• Limit alcohol consumption to moderate amounts (no more than one drink per day for women and two drinks per day for men) 2

Medication Management

Medication Selection Based on Patient Characteristics:

• For patients with established ASCVD or high cardiovascular risk: Prioritize SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefit 1
• For patients with CKD: Prioritize SGLT2 inhibitors with proven renal benefit 1
• For patients with heart failure: Prioritize SGLT2 inhibitors 1

Insulin Therapy Considerations:

• Use the shortest needles available (4-mm pen and 6-mm syringe needles) 3
• Avoid intramuscular injections, especially with long-acting insulins, to prevent severe hypoglycemia 3
• Rotate injection sites to prevent lipohypertrophy 3
• Prescribe glucagon for all individuals taking insulin or at high risk for hypoglycemia 2

Monitoring and Follow-up

• Monitor HbA1c every 3 months until target is reached, then at least every 6 months 1
• Test blood glucose frequently and at critical times 2
• Use fasting plasma glucose values to titrate basal insulin and both fasting and postprandial glucose values to titrate mealtime insulin 3
• Screen regularly for complications (retinopathy, nephropathy, etc.) 2
• Maintain LDL cholesterol <100 mg/dL (2.60 mmol/L) 2
• Maintain blood pressure <130/80 mm Hg 2

Common Pitfalls and How to Avoid Them

1. Clinical inertia: Studies show delays in treatment intensification are common, especially for blood pressure and lipid management 4. Implement prompt therapy intensification when glycemic targets are not met.

2. Hypoglycemia risk: Use insulin analogs instead of human insulin to reduce risk 2, and educate patients about recognizing and managing hypoglycemia symptoms 2.

3. Medication adherence: Poor adherence significantly impacts outcomes. Regular follow-up and simplified regimens can improve adherence.

4. Inadequate monitoring: Regular blood glucose monitoring is essential for effective insulin therapy 3. Ensure patients have access to and understand how to use monitoring devices.

5. Failure to address comorbidities: Manage cardiovascular risk factors alongside glycemic control. Patients should maintain LDL cholesterol <100 mg/dL and blood pressure <130/80 mm Hg 2.

Special Considerations for Older Adults

For older adults with limited life expectancy or when palliative care is needed:

• Simplify regimens and relax strict glucose and blood pressure control 2
• Focus on preventing hypoglycemia and symptomatic hyperglycemia 2
• Consider withdrawing lipid-lowering therapy 2
• Prioritize comfort, prevention of distressing symptoms, and quality of life 2

The evidence clearly shows that early, aggressive treatment of uncontrolled diabetes significantly reduces the risk of complications and improves outcomes. While insulin has traditionally been the mainstay for severely uncontrolled diabetes, newer agents like GLP-1 receptor agonists have shown comparable or even superior efficacy in some studies 5, offering alternatives based on individual patient characteristics and comorbidities.